An Assessment Team will be developed to study the medical care outcomes of persons with low back pain. Back pain is proposed as a focus because it is extremely common in the populations served by Medicare. Back problems result in frequent hospitalization, surgery, and use of expensive diagnostic tests, and wide geographic variations in the use of these services are well documented. We hypothesize that these variations are largely related to differing physician practice styles, and that overall utilization can be reduced with no adverse effect on patient outcomes. The Assessment Team will be based in the Department of Health Services at the University of Washington, with extensive involvement by the relevant clinical departments of the School of Medicine, by the Group Health Cooperative (HMO) of Puget Sound, and by the Maine Medical Assessment Foundation. An Advisory Board is comprised of community physicians; major hospital, medical, and health care payer associations; and international experts. The specific aims of the Team are to (1) characterize geographic variation and outcomes of lumbar spine surgery; (2) characterize the content and outcome of non-surgical hospitalizations for back problems; (3) examine the value and optimal sequence of expensive diagnostic tests for spine conditions; and (4) disseminate relevant findings to modify clinical practice styles. Initial studies will focus on spinal stenosis, which is the leading diagnosis associated with both surgical and medical hospitalizations for back pain in persons over age 65. Because herniated intervertebral disc is also a common condition in this age group, as well as in the younger population served under SSDI, outcomes of care for this condition will also be investigated. The study of lumbar spine surgery will include a methodologic review and synthesis of existing literature on the outcomes of laminectomy, discectomy, and fusion. It will further characterize geographic variations in these procedures by use of hospital claims data. The frequency of mortality, readmission, reoperation and nursing home placement will assessed with Medicare data. Symptomatic, functional, and cost outcomes will assessed in a clinical cohort study of surgical patients. These diverse data will provide probabilities, utilities, and costa for a formal decision analysis of the surgical decision. Similarly, variability in medical admissions for back pain will be assessed with Medicare and other claims data. These data will also identify the most commonly used diagnostic and therapeutic procedures. Through literature review, physician interviews, and patient interviews, the potential for shifting these activities to the outpatient setting will be assessed. Literature synthesis will also be used to examine the sensitivity, specificity, side effects, and costs of expensive technologies used to diagnose herniated discs and spinal stenosis (e.G., myelography, MRI, discography). These data will be used to construct a decision analysis to clarify the role and optimal sequence of these tests. Finally, the Team will provide targeted feedback of data on hospitalization and surgery rates to physicians and hospitals. Guidelines for use of these services will ge disseminated by professional and payer organizations and innovative CME efforts. New decision aids for both physicians and patients will incorporate data from all the assessment activities.